Is working at a community health center worth it when graduating with ~300k in debt

[MateoGM416]

Hello,

I'm an M2 and am interested in either peds or FM and I would prefer to work for the uninsured in suburban or rural community clinic setting, but I do not know anything about how financial compensation works as a doc and if that would be a viable option financially if I'm graduating with at least 300k in debt. I know NHSC is an option for paying off loans but I've heard that it is pretty particular and stringent when it comes to who qualifies and its requirements. I also don't know if that's something people enjoy doing after residency as opposed to going into private practice or working for a health system. I ideally would like to be out of debt ASAP after I finish residency but also work ~40 hours a week or less. I don't have any doctors in my family or know any doctors so I would appreciate any advice.

Thanks!

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[Sardonix]

Look into PSLF. You don't even need to work at an FQHC to qualify for it and if you meet all terms and minimum payments you are done with your debt while having actually paid minimal amounts for it. That said, it will be sitting there for the 10yrs (120 qualifying payments) until it is forgiven.

Your commitment to the underserved is admirable. But wait until you have seen this type of patient population in residency prior to fully committing to working with them day in/day out.

 

[smq123]

Hello,

I'm an M2 and am interested in either peds or FM and I would prefer to work for the uninsured in suburban or rural community clinic setting, but I do not know anything about how financial compensation works as a doc and if that would be a viable option financially if I'm graduating with at least 300k in debt. I know NHSC is an option for paying off loans but I've heard that it is pretty particular and stringent when it comes to who qualifies and its requirements. I also don't know if that's something people enjoy doing after residency as opposed to going into private practice or working for a health system. I ideally would like to be out of debt ASAP after I finish residency but also work ~40 hours a week or less. I don't have any doctors in my family or know any doctors so I would appreciate any advice.

Thanks!

Is it financially viable? Sure.

Is it financially comfortable? That depends on a wide range of factors. Are you single or do you have/plan to have multiple children? How many children? Is your partner a high earner or would you be the primary breadwinner? Where do you want to live?

I worked in an FQHC for 10 years, staying past my NHSC obligation period. The patients were challenging and the environment isn’t for everyone but I enjoyed it, for the most part. But it can be hard to know how you’ll react to the setting. I’ve seen lots of good, caring clinicians get burnt out on the challenging environment and quit.

 

[cabinbuilder]

Hello,

I'm an M2 and am interested in either peds or FM and I would prefer to work for the uninsured in suburban or rural community clinic setting, but I do not know anything about how financial compensation works as a doc and if that would be a viable option financially if I'm graduating with at least 300k in debt. I know NHSC is an option for paying off loans but I've heard that it is pretty particular and stringent when it comes to who qualifies and its requirements. I also don't know if that's something people enjoy doing after residency as opposed to going into private practice or working for a health system. I ideally would like to be out of debt ASAP after I finish residency but also work ~40 hours a week or less. I don't have any doctors in my family or know any doctors so I would appreciate any advice.

Thanks!

Being out of debt ASAP + working less than 40hr/s a week do not go together. To get out of debt you will have to work as much as you can. It took me 14 years to pay my student loans off. You are in the wrong profession my friend. Need to change your mind set if you plan to be loan debt free.

 

[cj_cregg]

If you work in an FQHC or rural health center, you will almost certainly qualify for NHSC loan forgiveness or a similar state program. The FQHCs I'm familiar with had lower salaries but reasonable work hours and benefits, as well as additional in office resources like social work, behavioral health, and clinical pharmacists who can help to offload some of the extra challenges of working with these patient populations. Rural health centers tend to pay pretty well but not necessarily have those extra staff and resources. Also, can't speak to peds, but for FM at least most jobs tend to be salaried the first few years so working extra hours gets you no extra money - once you transition to production, you could theoretically decide to work more/see more patients and get paid more, but that doesn't always work out IRL when your staff have to do the same.

 

[MateoGM416]

Is it financially viable? Sure.

Is it financially comfortable? That depends on a wide range of factors. Are you single or do you have/plan to have multiple children? How many children? Is your partner a high earner or would you be the primary breadwinner? Where do you want to live?

I worked in an FQHC for 10 years, staying past my NHSC obligation period. The patients were challenging and the environment isn’t for everyone but I enjoyed it, for the most part. But it can be hard to know how you’ll react to the setting. I’ve seen lots of good, caring clinicians get burnt out on the challenging environment and quit.

I guess my first question is how does compensation work in these cases? Who is actually writing your paychecks if a patient is uninsured and has no money to pay for services.

I want to live in the South, Midwest, or mountain west, and the areas in particular I am interested in are below the national average in cost-of-living... I am single but I would one day like to start a family with a couple of kids. I guess being the primary breadwinner is out of the question with those wants in mind?

Also, what makes that patient population and environment challenging?

Being out of debt ASAP + working less than 40hr/s a week do not go together. To get out of debt you will have to work as much as you can. It took me 14 years to pay my student loans off. You are in the wrong profession my friend. Need to change your mind set if you plan to be loan debt free.

There's no need for the lecturing or telling me I'm in the wrong profession, but I appreciate the advice.

 

[smq123]

I guess my first question is how does compensation work in these cases? Who is actually writing your paychecks if a patient is uninsured and has no money to pay for services.

I want to live in the South, Midwest, or mountain west, and the areas in particular I am interested in are below the national average in cost-of-living... I am single but I would one day like to start a family with a couple of kids. I guess being the primary breadwinner is out of the question with those wants in mind?

Also, what makes that patient population and environment challenging?

- it is unusual for an FQHC to be 100% uninsured. There are a few (usually dedicated to specific populations, like the homeless) but generally most FQHCs will have some insured patients. Most of those will be the bronze marketplace plans or Medicaid. There may be some Medicare.

The rest of the money comes from federal grants. Very very lucky FQHCs will have private grants or donations. Mackenzie Scott (Jeff Bezos’s ex wife) recently donated a bunch of money to some FQHCs.

- No, being primary breadwinner isn’t out of the question, especially if you’re ok living in a rural area. Rural FQHCs tend to pay better and the cost of living is lower. But having a high earning partner makes things easier, obviously.

- the patients tend to have lives that are very chaotic and dysfunctional, which makes regular continued care very challenging. It is hard to control a patient’s blood pressure when they can’t afford to buy the pills consistently. It’s hard to adjust a patient’s diabetes medications when they can’t come in for regular visits because they’re migrant farm workers and don’t know where they’ll be living in 3 months. And then when they do come in, they will now have 7 additional pressing problems that you’ll have to address in fifteen minutes.

 

[cabinbuilder]

There's no need for the lecturing or telling me I'm in the wrong profession, but I appreciate the advice.

I am not lecturing you, I'm all about the reality check. Nobody gets that kind of debt paid down working less than 40 hours a week. I get wanting a family with kids, etc. I am a mom too and went to med school with a 2 and 5 yr old. I worked a 60+ hour week all the way through. It's part of being a doctor, it's what you sign up for.

 

[cj_cregg]

I guess my first question is how does compensation work in these cases? Who is actually writing your paychecks if a patient is uninsured and has no money to pay for services.

I want to live in the South, Midwest, or mountain west, and the areas in particular I am interested in are below the national average in cost-of-living... I am single but I would one day like to start a family with a couple of kids. I guess being the primary breadwinner is out of the question with those wants in mind?

Also, what makes that patient population and environment challenging?



There's no need for the lecturing or telling me I'm in the wrong profession, but I appreciate the advice.

Good insight above from smq.

At FQHCs and RHCs, as above most patients are insured in the post-ACA world and you will be paid by your employer (the FQHC/RHC), who receives federal grants to keep up with costs. Pay tends to be lower at FQHCs compared to jobs where you're employed by a hospital system but still well into the six figures and more than enough to live a comfortable life if you're not somewhere with astronomical cost of living. For FM for example, the median salary these days is about $250k, FQHCs tend to pay in the $175k-225k range at least in my neck of the woods.

I see a handful of uninsured patients in my job now at an RHC and previously at my residency clinic - too wealthy to qualify for Medicaid, too poor to afford insurance out of pocket in some cases, in other cases they are undocumented immigrants who can't get health insurance or Amish/Mennonite folks who don't get health insurance. They pay out of pocket for their care. Sometimes the health system cuts them a break if they qualify financially. I suspect sometimes those bills don't get paid for a long time or at all. But my employer pays me the same regardless.

Mostly in states that did not expand Medicaid, or in areas with large immigrant (especially undocumented) communities, you will find larger pockets of patients with no insurance whatsoever and a relative lack of FQHCs/RHCs. This is where you tend to see charity clinics that are donor funded and pay MUCH less. They do tend to be overtly religiously oriented of the few I'm aware of. I know of one family doctor who went to work at one of these places, reading between the lines I think their pay was somewhere close to $100k in a large city with higher costs of living (but not to like NYC/LA levels), but they were very committed to the mission of that clinic and that's exactly what they wanted to be doing with that career, so they were happy to take that pay cut.

These are hard patients to take care of. It can be REALLY rewarding to be their PCP but it is hard. It's tough for them to get in to see specialists oftentimes so you need to be good at what you do and manage a lot of things yourself. As mentioned above there are a lot of things outside the walls of your clinic that affect their ability to access the best possible care. In some communities there's a lot of (often justified) distrust of healthcare providers you have to work really hard to overcome in order to take good care of them. There's a lot of trauma and mental illness that can lead to difficult interactions and relationships with these patients, and that makes it hard for them to take the steps they need to improve their health. In short, just a lot of things that make your ability to provide good care 10x harder than it would be for a person who has lived an easier, wealthier life. But....if you have the right personality and attitude to work with these folks, a good PCP can really be a game changer for their health and their life trajectory. I think of some of the patients I had during residency and the accomplishments they made just in that short time and I'm so proud and happy for them. Just started at my new job but already seeing some small victories and the patients are so appreciative. The work is hard but I'm enjoying it.

 

[voxveritatisetlucis]

Being out of debt ASAP + working less than 40hr/s a week do not go together. To get out of debt you will have to work as much as you can. It took me 14 years to pay my student loans off. You are in the wrong profession my friend. Need to change your mind set if you plan to be loan debt free.

How easy is it to find a job for 40 hours per week and then multiple locums type jobs for maybe an extra 20 hours per week. I know this probably varies by specialty but in general for primary care.

 

[MateoGM416]

- it is unusual for an FQHC to be 100% uninsured. There are a few (usually dedicated to specific populations, like the homeless) but generally most FQHCs will have some insured patients. Most of those will be the bronze marketplace plans or Medicaid. There may be some Medicare.

The rest of the money comes from federal grants. Very very lucky FQHCs will have private grants or donations. Mackenzie Scott (Jeff Bezos’s ex wife) recent donated a bunch of money to some FQHCs.

- No, being primary breadwinner isn’t out of the question, especially if you’re ok living in a rural area. Rural FQHCs tend to pay better and the cost of living is lower. But having a high earning partner makes things easier, obviously.

- the patients tend to have lives that are very chaotic and dysfunctional, which makes regular continued care very challenging. It is hard to control a patient’s blood pressure when they can’t afford to buy the pills consistently. It’s hard to adjust a patient’s diabetes medications when they can’t come in for regular visits because they’re migrant farm workers and don’t know where they’ll be living in 3 months. And then when they do come in, they will now have 7 additional pressing problems that you’ll have to address in fifteen minutes.

Thank you for explaining those things.

Good insight above from smq.

At FQHCs and RHCs, as above most patients are insured in the post-ACA world and you will be paid by your employer (the FQHC/RHC), who receives federal grants to keep up with costs. Pay tends to be lower at FQHCs compared to jobs where you're employed by a hospital system but still well into the six figures and more than enough to live a comfortable life if you're not somewhere with astronomical cost of living. For FM for example, the median salary these days is about $250k, FQHCs tend to pay in the $175k-225k range at least in my neck of the woods.

I see a handful of uninsured patients in my job now at an RHC and previously at my residency clinic - too wealthy to qualify for Medicaid, too poor to afford insurance out of pocket in some cases, in other cases they are undocumented immigrants who can't get health insurance or Amish/Mennonite folks who don't get health insurance. They pay out of pocket for their care. Sometimes the health system cuts them a break if they qualify financially. I suspect sometimes those bills don't get paid for a long time or at all. But my employer pays me the same regardless.

Mostly in states that did not expand Medicaid, or in areas with large immigrant (especially undocumented) communities, you will find larger pockets of patients with no insurance whatsoever and a relative lack of FQHCs/RHCs. This is where you tend to see charity clinics that are donor funded and pay MUCH less. They do tend to be overtly religiously oriented of the few I'm aware of. I know of one family doctor who went to work at one of these places, reading between the lines I think their pay was somewhere close to $100k in a large city with higher costs of living (but not to like NYC/LA levels), but they were very committed to the mission of that clinic and that's exactly what they wanted to be doing with that career, so they were happy to take that pay cut.

Dang well 50k doesn't seem like that much of a paycut, did that doctor you know working for 100k go to that charity clinic after he had been practicing awhile or relatively early in his career? Some of my classmates volunteer at a local community clinic and all of the physicians who work there are either late in their career and doing it cause they don't need the money, or practice at a regular clinic most of the week and work at that clinic once every or every other week, which I guess is also an option

These are hard patients to take care of. It can be REALLY rewarding to be their PCP but it is hard. It's tough for them to get in to see specialists oftentimes so you need to be good at what you do and manage a lot of things yourself. As mentioned above there are a lot of things outside the walls of your clinic that affect their ability to access the best possible care. In some communities there's a lot of (often justified) distrust of healthcare providers you have to work really hard to overcome in order to take good care of them. There's a lot of trauma and mental illness that can lead to difficult interactions and relationships with these patients, and that makes it hard for them to take the steps they need to improve their health. In short, just a lot of things that make your ability to provide good care 10x harder than it would be for a person who has lived an easier, wealthier life. But....if you have the right personality and attitude to work with these folks, a good PCP can really be a game changer for their health and their life trajectory. I think of some of the patients I had during residency and the accomplishments they made just in that short time and I'm so proud and happy for them. Just started at my new job but already seeing some small victories and the patients are so appreciative. The work is hard but I'm enjoying it.

I appreciate your insight, I figured patient life instability and other issues outside of a PCP's or patient's control would contribute to the difficulty like you and smq you said. Do these patients tend to be more abrasive than patients at a regular primary care clinic or hospital? Also, how common is it anecdotally to see the sort of longitudinal positive life changes like you might see with patients at a regular primary care clinic?

 

[smq123]

I appreciate your insight, I figured patient life instability and other issues outside of a PCP's or patient's control would contribute to the difficulty like you and smq you said. Do these patients tend to be more abrasive than patients at a regular primary care clinic or hospital? Also, how common is it anecdotally to see the sort of longitudinal positive life changes like you might see with patients at a regular primary care clinic?

It varies.

Some of my patients at the FQHC were really lovely and grateful. They appreciated that they could come to a "community place" and get care from a US-trained MD who "took the time to listen" (their direct words). When I was pregnant, a few took the time to hand-knit or hand-crochet baby blankets.

Some of the patients at the FQHC were just....not pleasant people. Life had dealt them a terrible hand, which is unfortunate, and they got really bitter and upset. So they took it out on literally everyone around them - usually, unfortunately, the lowest paid (the front desk staff, the medical assistants, etc.). Some were ashamed that they didn't have insurance, and so they responded by being especially snooty.

(A patient was seeing an NP at the clinic where I was working. One day she told him, to his face, "I got a job that offers good insurance, so I won't be coming to this ghetto-a** place any longer. I'll be going somewhere with REAL doctors and nurses." Which made it even more ironic when she lost that job 18 months later and came crawling back.)

Many of the patients at the university-affiliated clinic where I work are very pleasant. Many are doctors, nurses, lawyers, engineers, etc, and interacting with them is pretty easy.

Some are not pleasant, for the same reasons that some of the FQHC patients were unpleasant - life had not worked out the way that they would have wanted, so they took it out on everyone else. Some are wealthy and expect to be treated like VIPs.

I still have some patients with difficult socio-economic conditions that make their care extra challenging, but the frequency has gone wayyyy down. At the FQHC there were, like, a dozen of those a week. Here, there are 3 (?) a month.

 

[cj_cregg]

Thank you for explaining those things.



Dang well 50k doesn't seem like that much of a paycut, did that doctor you know working for 100k go to that charity clinic after he had been practicing awhile or relatively early in his career? Some of my classmates volunteer at a local community clinic and all of the physicians who work there are either late in their career and doing it cause they don't need the money, or practice at a regular clinic most of the week and work at that clinic once every or every other week, which I guess is also an option



I appreciate your insight, I figured patient life instability and other issues outside of a PCP's or patient's control twould contribute to the difficulty like you and smq you said. Do these patients tend to be more abrasive than patients at a regular primary care clinic or hospital? Also, how common is it anecdotally to see the sort of longitudinal positive life changes like you might see with patients at a regular primary care clinic?

This was their full time job straight out of residency. There are also plenty of docs who volunteer their time at free clinics as well!

In terms of personality challenges - I have definitely seen my fair share of wealthier patients who are unpleasant to work with and make threats to sue, report/complain, etc. I have also had wealthier patients who are polite but difficult to work with for other reasons (unreasonable expectations of my time or "do their own research" type people, usually). It is definitely an issue that spans multiple income brackets lol.

But, patients from communities with historically distrustful relationships with the healthcare field, poor health literacy/poor understanding of what's going on, or have previously faced discrimination are often scared or anxious when they're seeking care, and that sometimes manifests as anger, abrasiveness, snootiness, being demanding, etc. because sometimes they feel that's the only way they will be heard or respected. However, I will also say that if you can build a trusting connection with patients from those communities they are often incredibly grateful and appreciative. It is usually the patients who have felt the most ignored by the healthcare system, whatever the reason, who tell me "thank you for listening," "thank you for being my doctor," write me nice cards at Christmas, cried at my last appointment with them when I graduated residency, etc. and that feels really good as a PCP. I will say at my RHC job now the patients are UNBELIEVABLY kind and appreciative. I can count on one hand the number who have rubbed me the wrong way, and none of those were outright rude or demanding or anything like that.

I think how common it is to see those lifestyle changes depends on your patient population and the resources they have to help them actually make those changes. I think at both my jobs I have had more than enough patients making positive changes to keep my cup filled and keep me feeling optimistic about my work. Even if patients truly cannot make those changes, it still means a lot to them (and to me) to continue to try to work with them and try to figure things out together, and just accompany them through the ups and downs.

 

[VA Hopeful Dr]

I can't speak to FQHC work, but you can easily pay off that loan burden with family medicine while not killing yourself.

300k for a 10 year term at 7% is around $3500 per month.

My hospital system starts new FPs at around 240k. I live in SC which does have a state income tax.

Net pay every 2 weeks is 6500. So 13k/month. Subtract 3500 for loans, you still have 9.5k/month.

No one in my system fails to earn above that guarantee by the end of the 2nd year.

 

[voxveritatisetlucis]

I can't speak to FQHC work, but you can easily pay off that loan burden with family medicine while not killing yourself.

300k for a 10 year term at 7% is around $3500 per month.

My hospital system starts new FPs at around 240k. I live in SC which does have a state income tax.

Net pay every 2 weeks is 6500. So 13k/month. Subtract 3500 for loans, you still have 9.5k/month.

No one in my system fails to earn above that guarantee by the end of the 2nd year.

Yes but if you want to buy a house these days, 9.5k a month doesn’t get you very far. Mortgage on a 500k house is like 4.2k which only leaves you with 5k for food, investing, car etc.

 

[VA Hopeful Dr]

Yes but if you want to buy a house these days, 9.5k a month doesn’t get you very far. Mortgage on a 500k house is like 4.2k which only leaves you with 5k for food, investing, car etc.

All true, but that's why you should have read my last paragraph.

 

[cabinbuilder]

How easy is it to find a job for 40 hours per week and then multiple locums type jobs for maybe an extra 20 hours per week. I know this probably varies by specialty but in general for primary care.

I guess you could do this but most locum jobs are more than 2 shifts a week and you have to travel to get to them so probably would not be realistic. Also, most require 3-6 month commitment.

 

[Ironheme]

How easy is it to find a job for 40 hours per week and then multiple locums type jobs for maybe an extra 20 hours per week. I know this probably varies by specialty but in general for primary care.

Some hospital systems will have extra shifts you can pick up (UC, hospital, etc). So easy to find work as a PCP if you want it? Yes.

Your plan was my original plan, but I will tell you the burn out is real. I was working weekends doing locum while still holding down primary job M-F that was easily 50-60 hours per week (besides the locum). It's not sustainable for more than a few months like this for most people.

The only way I could see this working is if you went hospitalist, with one week on, one week off and worked a couple extra days of that. Agree with all the excellent advice you've been given. PSLF but have a back up plan in case that falls through. Live like a resident for a couple years but give yourself a little nice upgrade (extra $20-30k goes a long way when you've been living off $50k).

The biggest downfalls are the $$$$ items. I have pretty much never seen a new graduate avoid leasing/purchasing 1+ new car and/or buying a new house.

 

[InternistDO]

I have 400k in debt and doing PSLF. It's substantially less restrictive than NHSC--just make 10 years of the minimum payments (and residency counts assuming you aren't at a for profit hospital) while working at a nonprofit institution and the loans are forgiven. No being stuck with the same employer or meeting specific geographic requirements.

I have no real worries about money and I work 36hrs a week in an extremely HCOL city doing primary care. But I'm a pretty low maintenance person and my partner also works.

I agree you should wait and see what underserved rural care looks like before signing your life away--even in a city it can be a difficult job managing socially and medically complex patients, often without specialist support. In a rural area you can really be out on your own. But it can be very satisfying as long as you don't compare your salary to your med school classmates.

 

[MateoGM416]

I have 400k in debt and doing PSLF. It's substantially less restrictive than NHSC--just make 10 years of the minimum payments (and residency counts assuming you aren't at a for profit hospital) while working at a nonprofit institution and the loans are forgiven. No being stuck with the same employer or meeting specific geographic requirements.

I have no real worries about money and I work 36hrs a week in an extremely HCOL city doing primary care. But I'm a pretty low maintenance person and my partner also works.

I agree you should wait and see what underserved rural care looks like before signing your life away--even in a city it can be a difficult job managing socially and medically complex patients, often without specialist support. In a rural area you can really be out on your own. But it can be very satisfying as long as you don't compare your salary to your med school classmates.

If you don't mind me asking, how much are your minimum payments? Can you start making those payments during residency?

 

[Keona]

If you don't mind me asking, how much are your minimum payments? Can you start making those payments during residency?

You can start payments during residency and if you can afford it will count towards your years for loan forgiveness. My payments are still under calculated as an attending because I started practicing shortly before Covid (graduated in 2018) started and the income adjustment has been held for a bit from that so I’m not sure how bad they’ll be this next year. The federal loans I have with the paye plan go away after 20 years of income based payments. My payments are 1960 currently, I’ve got 11.5 more years of payments left I think if I’ve calculated it correctly (waiting on them to send the amount of payments still owed, they’re supposed to adjust for all this summer). I made payments throughout residency. My husband also still has another year of loan payments so that also decreases the amount of loan repayment that I’m expected to do. He did traditional repayment so it was 10 years of loan repayments and he didn’t make payments during the Covid pause. He only had loans from a masters degree so much more able for us to do that traditionally. I think when his loans are paid off they expect us to still contribute that same amount that we’ve been paying on his to my student loans. The amount of loan you can be asked to pay a month caps out. I think with the save plan you’d be making minimal payments during residency but it takes that plan 25 years to reach forgiveness level. Before you graduate med school you should have to do an exit interview with your schools financial aid person to go through the different payment options and help figure out what’s the best option for you.

 

[FrustratedFamDoc]

There’s a lot to consider with planning an FM career after residency. If family with kids is important, a good school system probably is too. I went to a public school in a good town and had an excellent education. Many are vying for private school these days. Will this be available where you want to live?

#2. Will your spouse actually be comfortable with living there and the lifestyle it brings?

#3. How you are paid is almost more important that how much. After the guarantee expires, you’re generally switched over to production based, under a typical contract. Say you generated the equivalent of a $250k salary last year off of production. They may try to give you a $180k base and the allure of ‘you’re going to be making much more than this in the year. We true up every 6 months.’ What this means is you take a substantial pay cut until half the year is over, perhaps barely covering col, and then when you get your true up, you play catch up until the next one 6 months later. Don’t let them screw you like this.

The best way to go is still finish residency, find a job in a town that won’t cause you to have a divorce, that generates a great salary, build a great practice by being super doc, work your tail off, and having a clear and mutually agreed upon, with your spouse, written down asap plan on getting out of debt. Also, Coming in as the new person that has a work allergy is not a good look.

Physician divorce rates are high for a reason. Do not let this be you. Child support, alimony and student loan payments… ouch.

 

[Ironheme]

find a job in a town that won’t cause you to have a divorce,

 

[MateoGM416]

There’s a lot to consider with planning an FM career after residency. If family with kids is important, a good school system probably is too. I went to a public school in a good town and had an excellent education. Many are vying for private school these days. Will this be available where you want to live?

#2. Will your spouse actually be comfortable with living there and the lifestyle it brings?

#3. How you are paid is almost more important that how much. After the guarantee expires, you’re generally switched over to production based, under a typical contract. Say you generated the equivalent of a $250k salary last year off of production. They may try to give you a $180k base and the allure of ‘you’re going to be making much more than this in the year. We true up every 6 months.’ What this means is you take a substantial pay cut until half the year is over, perhaps barely covering col, and then when you get your true up, you play catch up until the next one 6 months later. Don’t let them screw you like this.

The best way to go is still finish residency, find a job in a town that won’t cause you to have a divorce, that generates a great salary, build a great practice by being super doc, work your tail off, and having a clear and mutually agreed upon, with your spouse, written down asap plan on getting out of debt. Also, Coming in as the new person that has a work allergy is not a good look.

Physician divorce rates are high for a reason. Do not let this be you. Child support, alimony and student loan payments… ouch.

Wow thank you you've given me a lot to think about here

 

[VenusinFurs]

My first two jobs out of residency were at FQHCs, and basically my experiences are:

-The loan repayments are limited in number through the nhsc and if you are granted one the work requirements are very stringent, you are only allowed to take x number of days off in a year and if you exceed that number you have to pay a hefty penalty sometimes. If you want a flexible schedule don’t do this.
-FQHCs demand a lot, your patient population has a ton of barriers but you still get excessively pestered about quality measures often without any support to improve your numbers.
-You have very little autonomy and these orgs seem to attract a certain type of petty tyrant. In fact, my last boss basically has tried to ruin my career, though thankfully it seems she is unlikely to do any lasting harm. This could happen at any organization, and since I’ve only worked at two I have a very small sample size. But all I can say is you working for an underserved population for less money does not necessarily get you gratitude and respect from the people at the top, and even though they are working for a nonprofit organization their goals seem to be to work as little as possible and get as much money as possible by harassing the staff and doctors who do the real work.

But I must also speak to advantages, namely the FTCA is a huge one, and my experience at both orgs was the majority of the patients were sweet, humble, hardworking and grateful and welcomed me into the community with open arms. I did a locums stint in a private practice in a wealthy California town recently and I can’t say I found all the patients to be quite as pleasant though a lot of them were. You get entitled people no matter where you work. Having a guaranteed salary was nice.

My recommendation would be to tighten your belt, look for pslf eligible orgs. My observation is younger people don’t seem to last as long at FQHCs, maybe it takes the patience and resilience of an older doctor to be able to handle the crappy aspects of these jobs.

 

[MateoGM416]

My first two jobs out of residency were at FQHCs, and basically my experiences are:

-The loan repayments are limited in number through the nhsc and if you are granted one the work requirements are very stringent, you are only allowed to take x number of days off in a year and if you exceed that number you have to pay a hefty penalty sometimes. If you want a flexible schedule don’t do this.
-FQHCs demand a lot, your patient population has a ton of barriers but you still get excessively pestered about quality measures often without any support to improve your numbers.
-You have very little autonomy and these orgs seem to attract a certain type of petty tyrant. In fact, my last boss basically has tried to ruin my career, though thankfully it seems she is unlikely to do any lasting harm. This could happen at any organization, and since I’ve only worked at two I have a very small sample size. But all I can say is you working for an underserved population for less money does not necessarily get you gratitude and respect from the people at the top, and even though they are working for a nonprofit organization their goals seem to be to work as little as possible and get as much money as possible by harassing the staff and doctors who do the real work.

But I must also speak to advantages, namely the FTCA is a huge one, and my experience at both orgs was the majority of the patients were sweet, humble, hardworking and grateful and welcomed me into the community with open arms. I did a locums stint in a private practice in a wealthy California town recently and I can’t say I found all the patients to be quite as pleasant though a lot of them were. You get entitled people no matter where you work. Having a guaranteed salary was nice.

My recommendation would be to tighten your belt, look for pslf eligible orgs. My observation is younger people don’t seem to last as long at FQHCs, maybe it takes the patience and resilience of an older doctor to be able to handle the crappy aspects of these jobs.

So what are signs and how does one spot such malignant organizations before signing a contract with them?

 

[smq123]

So what are signs and how does one spot such malignant organizations before signing a contract with them?

- You can ask how quality measures are tracked and rewarded. Of course, be aware that they may give you a minimally accurate "feel good" answer (i.e. they'll be blowing smoke up your butt) but if you have a decent BS detector, you can figure out how much of what they're telling you is true.

- You can ask what support you will have to meet your quality measure goals. Be sure to ask ACTUAL CLINICIANS this question (if you're allowed to talk to them) because HR won't have a clue and will give you some vague answer that is totally inaccurate.

- I would recommend asking people how long they've been there. There are some very well run FQHCs where people have been there for several years. Part of the issue is is that many FQHCs have such high turnover that you could interview with a medical director who seems really reasonable and nice, only to have that person leave 6 months into your job and you end up stuck with a jerk. On the plus side, that jerk is also likely to leave after just a few more months, so it becomes a bit of a waiting game.

 

[MateoGM416]

- You can ask how quality measures are tracked and rewarded. Of course, be aware that they may give you a minimally accurate "feel good" answer (i.e. they'll be blowing smoke up your butt) but if you have a decent BS detector, you can figure out how much of what they're telling you is true.

Could you give an example of what a 'quality measure' is in a FQHC context?? I'm just a second year student so I don't really know what that means.

 

[smq123]

Could you give an example of what a 'quality measure' is in a FQHC context?? I'm just a second year student so I don't really know what that means.

So the government produces a list of quality measures that all clinicians are advised to meet. How stringently you're expected to meet those depends on your employer, whether or not you take insurance, etc. One of the reasons why FQHCs are so obsessed with quality measures is because there are generally financial bonuses/rewards for meeting a lot of those quality measures, and when you're an FQHC, every dollar counts.

The ones commonly focused on:
- What percentage of your patients are appropriately screened for cervical cancer with pap smears?
- What percentage of your patients are appropriately screened for colon cancer with colonoscopy or other stool tests (such as Cologuard)?
- What percentage of your diabetic patients have an A1C below 8?
- What percentage of your patients with high blood pressure have their blood pressure well controlled (usually defined as having a blood pressure under 130/80)?
- What percentage of your pediatric patients are fully vaccinated appropriately?
- What percentage of your pediatric patients get dental fluoride at the appropriate time?
- What percentage of your patients are screened for depression annually?
- What percentage of your patients who smoke tobacco are counseled on quitting?

That's just some of them. Believe it or not, there are more.

 

[Ironheme]

So the government produces a list of quality measures that all clinicians are advised to meet. How stringently you're expected to meet those depends on your employer, whether or not you take insurance, etc. One of the reasons why FQHCs are so obsessed with quality measures is because there are generally financial bonuses/rewards for meeting a lot of those quality measures, and when you're an FQHC, every dollar counts.

The ones commonly focused on:
- What percentage of your patients are appropriately screened for cervical cancer with pap smears?
- What percentage of your patients are appropriately screened for colon cancer with colonoscopy or other stool tests (such as Cologuard)?
- What percentage of your diabetic patients have an A1C below 8?
- What percentage of your patients with high blood pressure have their blood pressure well controlled (usually defined as having a blood pressure under 130/80)?
- What percentage of your pediatric patients are fully vaccinated appropriately?
- What percentage of your pediatric patients get dental fluoride at the appropriate time?
- What percentage of your patients are screened for depression annually?
- What percentage of your patients who smoke tobacco are counseled on quitting?

That's just some of them. Believe it or not, there are more.

The fun part is when you reach one they either say 'good job! the new goal for this same metric is x' or 'since we met that metric, we're going to focus on metric y now in addition.'

 

[brianmartin]

this is why PSLF exists